National Center for Immunization & Respiratory Diseases Measles -- 2019 Melinda Wharton, MD, MPH Director, Immunization Services Division Centers for Disease Control and Prevention National Vaccine Advisory Committee Washington, D.C. June 4, 2019 Global Measles Update Measles -- 2019 2019 WHO case distribution Measles - 05 Measles cases (Lab+Epi+Clinical) 10000 15000 20000 25000 30000 35000 40000 45000 50000 55000 60000 65000 70000 75000 80000 - 5000 08 0 Notes: Based Notes:data on received 2019 Region 2015-01 2015-02 2015-03 2015-04 2015-05 2015-06 2015-07 (2015-2 2015-08 2015-09 - 05 2015-10 - Data Source: IVB DatabaseDataIVB Source: 2015-11 2015-12 2016-01 2016-02 2016-03 019) AFR AMR2016 EMR -04 2016-05 2016-06 2016-07 2016-08 by - 2016-09 This is surveillanceisThis thelasthencemonth(s), data,the for 2016-10 Month of onsetMonthof 2016-11 month and 2016-12 2017-01 2017-02 2017-03 2017-04 EUR 2017-05 2017-06 2017-07 2017-08 SEAR 2017-09 2017-10 2017-11 2017-12 WPR 2018-01 2018-02 2018-03 2018-04 2018-05 data may databe may incomplete. 2018-06 2018-07 2018-08 2018-09 2018-10 2018-11 2018-12 2019-01 2019-02 2019-03 2019-04 2019-05 Number of Reported Measles Cases (6M period) Top 10* Country Cases Madagascar 84765 Ukraine 56094 India** 19544 Nigeria 10610 Brazil 8663 Philippines 7518 Yemen 6779 Kazakhstan 5902 Thailand 5784 Venezuela (Bolivarian 5668 Republic of) Notes: Based on data received 2019-05 - Surveillance data from 2018-10 to 2019-03 - * Countries with highest number of cases for the period **WHO classifies all suspected measles cases reported from India as measles clinically compatible if a specimen was not collected as per the algorithm for classification of suspected measles in the WHO VPD Surveillance Standards. Thus numbers might be different between what WHO reports and what India reports. Ten countries with the highest numbers of measles cases in the WHO European Region, April 2018–March 2019 Ukraine 78659 Kazakhstan 5908 Georgia 4678 Out of 114 798 measles cases reported for April 2018 to March Israel 3755 2019, 104 907 (91%) cases were reported by these 10 countries. Kyrgyzstan 2534 Russian Federation 2422 Italy* 2107 France 2028 Serbia 1426 Romania 1390 0 10000 20000 30000 40000 50000 60000 70000 80000 90000 Number of cases *Based on data from April 2018 to February 2019 Data source: Monthly aggregated and case-based data reported by Member States to WHO/Europe directly or via ECDC/TESSy data as of 06 May 2019 5 UNICEF-WHO Philippines: Measles Outbreak, Situation Report 11, 27 May 2019 PAHO. Measles-Rubella Surveillance Bulletin Vol. 25, No. 19 Measles – United States, 2019 Measles -- 2019 2019 US measles outbreaks . From January 1 to May 24, 2019, 981 people from 26 states have been reported as having measles cases (increase of 41 cases from May 24th) – Greatest number of cases reported in the U.S. since 1992 and since measles was declared eliminated in 2000 . Measles outbreaks (3 or more linked cases) currently ongoing in: – New York (since 2018): Rockland County, New York City – California: Butte County, Los Angeles County, Sacramento County – Michigan – Georgia – Maryland – Pennsylvania – Washington States that Have Reported Measles Cases in 2019 January 1-May 31, 2019 Source Countries for International Importations (n=58) –United States, January 1-May 31, 2019* Other 21% Philippines 26% Lithuania 3% France 3% Germany 3% Thailand Ukraine 5% 16% Vietnam 7% Israel 16% *Data are preliminary as of May 31, 2019. Percentages are of all 58 international importations. What CDC is doing to address the outbreak . Implemented an Incident Management Structure (IMS) within the National Center for Immunization and Respiratory Diseases (NCIRD) . Investing in state and local health departments for public health infrastructure and laboratory capacity to support front-line response to suspected and confirmed measles cases . Providing rapid assistance on the ground during outbreak investigations, through a formal request by the state health department . Epidemiology: – Gathering data reported by states on confirmed measles cases and evaluating and monitoring these data from a national perspective What CDC is doing to address the outbreak . Communications: – Communicating with public health officials from states with reported measles cases and providing technical assistance – Developed a toolkit with resources for physicians about measles and vaccines – Doing outreach to rabbinical, camp, and medical associations to help spread clear, consistent, and credible vaccine information through trusted sources . Laboratory: – Testing specimens for difficult diagnostic cases of suspected measles infection when requested by states – Using Advanced Molecular Detection (AMD) methods to determine measles virus genotypes and strains Strategy: Dismantle Barriers to Access Driver #1 - Minimize vaccine costs to patients - Connect parents with health care providers Access to - Find new opportunities to vaccinate and minimize missed chances Vaccines Strategy: Identify, Reach, and Assist Communities at Risk Driver #2 - Leverage data to identify pockets of low vaccination before an outbreak occurs Pockets of - Work with health partners and providers to reach groups at risk Low - Create tailored, effective, and empathetic materials and approaches to improve Vaccination MMR vaccination among at-risk communities Strategy: Immunize Against Bad Information with Accurate, Persuasive Communications Driver #3 - Contain and counter false safety and efficacy claims Bad - Partner with health agencies, providers, and other stakeholders Information to educate the public and policy makers - Empower health care providers to make a positive case for vaccines For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. State Response to the Current Measles Outbreak Kim Martin, Director, Immunization Policy National Vaccine Advisory Committee (NVAC) Meeting, June 2019 The Association of State and Territorial Health Officials (ASTHO) • The Association of State and Territorial Health Officials (ASTHO) is the national nonprofit organization representing the state and territorial public health agencies of the United States, the U.S. Territories, and the District of Columbia. ASTHO's members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound public health policy, and to assuring excellence in state-based public health practice. • Strategic priorities: • Improve Public Health Through Capacity Building, Technical Assistance and Thought Leadership • Advocate for Resources and Policies that Improve the Public’s Health and Well-being • Develop Strong and Effective State and Territorial Health Officials Measles State Response Activities • Enhance surveillance • Utilize Incident Command System (ICS) and Emergency Management Assistance Compact (EMAC) • Inform the public of the outbreak and locations where exposures may have occurred • Educate patients and their contacts about the mode of transmission • Implement control activities to limit virus transmission ○ Provide measles vaccine clinics ○ Assess immunity of contacts of cases ○ Implement isolation and quarantine • Analyze the outbreak to determine if there is evidence of population immunity gaps that require public health action CDC, as of May 24, 2019 Media Response • ASTHO held two media desk side briefings • Many of our members held multiple press interviews and wrote Op-Ed pieces on the importance and benefits of immunizations which was covered in such national media outlets as NBC, Fox, CNN, US News and World Report, USA Today, The Hill, WIRED, Stat, Governing, and the Washington Post • John Wiesman (SHO-WA), ASTHO Immediate Past President, testified before the Senate HELP Committee https://www.cnn.com/2019/01/30/health/measles-outbreak-new-york-washington-update-bn/index.html State Challenges during the Current Outbreak • Expensive • State health agencies may have to pull resources from other programs to assist with the outbreak • Vaccine misinformation is hard to counter • Cases or contacts may not follow isolation and quarantine instructions CDC Long Term State Activities to Pharmacists can administer MMR Increase Vaccination Coverage vaccine in all but 3 states/cities (DC, NY • Expanding Access to Vaccinations and WV) • Increasing scope of practice for additional providers (e.g., pharmacists) Pharmacists may need a protocol, prescription or both to administer • Expanding Outreach vaccines • Providing education to the public to address misinformation or vaccine hesitancy • Providing messaging to providers about how In 19 states, pharmacists are to address misinformation and make strong not able to administer MMR vaccination recommendations to persons under 18 years old and in 17 states there is not an age restriction As of May 2019, over Vaccine Exemptions 900 individual cases of measles have been • Exemption Legislation: confirmed in 26 states Washington removed philosophical exemption for MMR Maine eliminated all non-medical exemptions Every state and becoming the fourth state without such Washington, D.C. have exemptions vaccination • Many other states are also considering bills to requirements for eliminate non-medical exemptions to school children who are starting vaccination requirements, including Arizona (HB school and allow 2162), Iowa (HF 206),